Remtulla et al.

BMC Health Services Research (2021) 21:269

https://doi.org/10.1186/s12913-021-06232-7

RESEARCH ARTICLE Open Access

Exploring the barriers and facilitators of

psychological safety in primary care teams:
a qualitative study
Ridhaa Remtulla1*† , Arwa Hagana2†, Nour Houbby2†, Kajal Ruparell2†, Nivaran Aojula2, Anannya Menon2,
Santhosh G. Thavarajasingam2 and Edgar Meyer3

Abstract
Background: Psychological safety is the concept by which individuals feel comfortable expressing themselves in a
work environment, without fear of embarrassment or criticism from others. Psychological safety in healthcare is
associated with improved patient safety outcomes, enhanced physician engagement and fostering a creative
learning environment. Therefore, it is important to establish the key levers which can act as facilitators or barriers to
establishing psychological safety. Existing literature on psychological safety in healthcare teams has focused on
secondary care, primarily from an individual profession perspective. In light of the increased focus on
multidisciplinary work in primary care and the need for team-based studies, given that psychological safety is a
team-based construct, this study sought to investigate the facilitators and barriers to psychological safety in primary
care multidisciplinary teams.
Methods: A mono-method qualitative research design was chosen for this study. Healthcare professionals from
four primary care teams (n = 20) were recruited using snowball sampling. Data collection was through semi-
structured interviews. Thematic analysis was used to generate findings.
Results: Three meta themes surfaced: shared beliefs, facilitators and barriers to psychological safety. The shared
beliefs offered insights into the teams’ background functioning, providing important context to the facilitators and
barriers of psychological safety specific to each team. Four barriers to psychological safety were identified: hierarchy,
perceived lack of knowledge, personality and authoritarian leadership. Eight facilitators surfaced: leader and leader
inclusiveness, open culture, vocal personality, support in silos, boundary spanner, chairing meetings, strong
interpersonal relationships and small groups.
(Continued on next page)

* Correspondence: [email protected]
†
Ridhaa Remtulla, Arwa Hagana, Nour Houbby and Kajal Ruparell are joint
co-first authors.
1
College of Medical and Dental Sciences, University of Birmingham,
Birmingham, UK
Full list of author information is available at the end of the article

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Remtulla et al. BMC Health Services Research (2021) 21:269 Page 2 of 12

(Continued from previous page)

Conclusion: This study emphasises that factors influencing psychological safety can be individualistic, team-based
or organisational. Although previous literature has largely focused on the role of leaders in promoting psychological
safety, safe environments can be created by all team members. Members can facilitate psychological safety in instances
where positive leadership behaviours are lacking - for example, strengthening interpersonal relationships, finding support
in silos or rotating the chairperson in team meetings. It is anticipated that these findings will encourage practices to
reflect on their team dynamics and adopt strategies to ensure every member’s voice is heard.
Keywords: Psychological safety, Teamwork, Primary care, General practice, Community

Background typical example of organisational resilience in healthcare

Psychological safety is the notion where individuals feel is the clinical handover which aims to facilitate foresight,
empowered to ask questions, admit mistakes or voice coping and recovery across the three levels of an
concerns without fear of negative repercussions from organisation [9]. Psychological safety is integral to
their team [1]. This concept has been explored in vary- maintaining organisational resilience. For example, an
ing contexts, including healthcare teams as psychological individual healthcare worker should feel able to raise a
safety can have an impact on patient safety and quality concern regarding a patient showing clinical signs of
of care. For healthcare professionals, psychological safety deteriorating (foresight) without fear of repercussions
creates an environment of trust and openness to discuss from seniors [9].
concerns and raise errors [2, 3]. This enables focus on In light of the well-evidenced benefits of psychological
providing high quality care, as opposed to managing the safety on healthcare teams, it is imperative to understand
expectations around voicing dissent and disagreement. It the key drivers which either facilitate or act as a barrier
has also been shown that psychological safety increases to establishing psychological safety. Specific facilitators
physician engagement [4], reduces burnout [5] and pro- which have already been identified in the literature in-
motes creativity [6]. clude those pertaining to the actions of leaders. For ex-
Appelbaum et al. surveyed 106 physicians in the ample, inclusive behaviours displayed by a leader such as
United States in order to investigate the perceptions of active invitation and appreciation of opinions from fel-
psychological safety and various other parameters in- low team members regardless of factors such as hier-
cluding the intention to report adverse events. Psycho- archical differences between a leader and team member
logical safety was found to be a direct predictor of the have been shown to facilitate psychological safety, exem-
intention to report adverse events by physicians, plified by Hirak et al’s [10] study which investigated the
highlighting the importance of psychological safety in correlation between leader inclusiveness and psycho-
creating safer care for patients [7]. Yanchus et al. investi- logical safety within a hospital [3, 11]. 224 team mem-
gated 11,726 healthcare workers including psychiatrists bers and 55 team leaders consisting of various hospital
and mental health nurses and determined that psycho- employees including doctors and nurses were surveyed,
logical safety was a direct predictor of turnover intent, and a positive relationship was found to exist within
emphasising the value of psychological safety in em- teams with more inclusive leaders [10].
ployee retention [8]. The literature also links psychological safety with
Indeed, the positive effects of psychological safety are change-oriented leadership. Change-oriented leadership
not limited to the individual or team level - rather, they as described by Yuki et al [12] refer to a set of behav-
permeate throughout the entire organisational infra- iours which promote innovation and change amongst
structure. This draws on the concept of organisational teams. For example, leaders who monitor the external
resilience, which can be described as how well supported environment to identify opportunities or potential threats
workers within an organisation are by across three spe- to a team, envision change, encourage innovation from
cific levels: the individual level, team level, and organisa- their subordinates and take on personal risk to enact
tional level [9]. Organisations which are resilient will change are seen to be change-oriented leaders. Ortega et al
facilitate workers to predict when a problem will arise [2] surveyed 107 nursing teams from various healthcare set-
(foresight), help individuals cope with problems which tings including primary care, intensive care and surgical set-
do occur (coping), and finally, find suitable ways to re- tings to investigate the relationship between psychological
cover from problems and prevent them in the future (re- safety and change-oriented leadership. Ortega et al. re-
covery) [9]. In turn, organisational resilience allows for ported that teams with change-oriented leaders also re-
problem management, which in a healthcare setting ported higher psychological safety within teams [2]. This
translates to improved patient safety measures – a has great implications for healthcare considering innovation
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 3 of 12

and non-traditional problem-solving strategies have histor- with limited studies examining the application of this
ically proved beneficial for the industry. construct within primary care teams [3, 11]. Arguably,
Ethical leaders i.e. individuals who demonstrate appro- the dynamics of teamwork can vary greatly between pri-
priate conduct themselves and by doing so encourage mary and secondary care multidisciplinary teams, thus a
and model exemplary conduct in their subordinates have focused exploration into psychological safety in these
also been cited in the literature as encouraging psycho- teams is warranted.
logical safety [13]. Gong et al [14] surveyed the opinions This qualitative study aimed to identify the specific
of feedback-seeking behaviour amongst subordinate barriers and facilitators of psychological safety in pri-
nurses and nurse leaders – in total, 60 leaders and 458 mary care teams. In the context of this study, barriers
subordinates were investigated. Teams, where leaders and facilitators refer to the various psychological, envir-
were deemed to be more ethical, were found to have onmental, interpersonal and organisational aspects of
higher levels of psychological safety and feedback- the multidisciplinary teams investigated. This was with a
seeking behaviour, particularly in teams with a high- view to establish behaviours that practices can imple-
power distance [14]. ment to harbour psychologically safe environments.
Barriers to psychological safety include workplace Given that the aim of this study is to identify barriers
bullying and hierarchy. Arnetz et al [15] investigated the and facilitators of psychological safety within primary
experience of workplace bullying amongst 331 registered care teams, an inductive study approach was deemed to
nurses from a specific American regional healthcare sys- be a more suitable study design as opposed to a trad-
tem. 36.9% of responders reported being bullied in the itional hypothetico-deductive approach [16]. The lack of
preceding 6 months [14]. An inverse relationship was specific premises to prove or disprove in the context of
found between personal experiences of disengagement psychological safety further supports the use of an in-
with work following personal bullying and psychological ductive methodology [17].
safety. Psychological safety was also associated with less
personal bullying as well as witnessing others being bul- Methods
lied [15]. Hierarchy has also been cited in the literature, Research philosophy and approach
with Appelbaum et al [7] investigating the influences of This study utilised a mono-method qualitative research
power distance and leader inclusiveness on psychological design which uses semi-structured interviews as the only
safety amongst 106 medical residents. A higher per- mode of data collection. The present study seeks to in-
ceived power distance predicted lower levels of psycho- vestigate multi-disciplinary team members’ perceptions
logical safety, whilst leader inclusiveness was positively of the facilitators and barriers of PS in primary care
correlated with psychological safety [7]. Higher levels of teams. Such perspectives and insights can only be ex-
psychological safety by consequence were positively cor- plored using a qualitative inquiry which, crucially, uses
related with intentions to report adverse medical events, methods such as open-ended interviewing to surface
further highlighting the importance of mitigating bar- opinions unconducive to quantification [18].
riers to psychological safety in order to maintain and im- This study employed an interpretivist approach which
prove patient safety. leverages qualitative methods to elicit narratives, capture
Whilst the literature makes clear that leaders are crucial stories and probe perceptions to articulate and concep-
in facilitating psychological safety in healthcare teams, tualise aspects of social phenomena which cannot be
there is less focus on how other team members may help quantified [19]. Interpretivism champions subjectivity,
to improve the psychological safety of their environment. and calls on the researcher to engage their own values
Circumstances where individuals speak up regardless of and beliefs, making their empathetic viewpoint a central
the leadership style they work under, suggests that other part of the research process [20]. Critical to the interpre-
factors external to the leader are at play in facilitating psy- tivist philosophy is its acknowledgement of multiple
chological safety. Given that the literature has a strong realities and therefore, this approach facilitates a deep
focus on the role of the leader, attempts should be made understanding of participants’ lived experiences [21].
to determine if general team behaviours, environmental The very notion that within the same context there
factors, team culture or innate personality traits contribute exist multiple realities experienced by different people
to the psychological safety of a team environment and if makes an interpretivist approach appropriate for the
so, what these factors may be. Likewise, are there alterna- present study exploring MDT members’ views on PS in
tive intrinsic or extrinsic factors that individuals may pos- primary care teams. By exploring PS through the lens
sess which can facilitate or impede the establishment of a of different MDT members, this research acknowledges
psychologically safe environment. the complexity of the social world and seeks to develop
Most of these findings on psychological safety in a deep understanding of the phenomenon under
healthcare teams however, focuses on secondary care, investigation.
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 4 of 12

This study applies an inductive approach to theory been anonymised due to the inclusion of direct quotes
development, which recognises the existence of a gap being used in this report. All recruitment was in line
between observed data and derived conclusions [22]; a with the approved ethics protocol. A brief synopsis out-
gap filled with underlying complexities which cannot lining the study purpose and objectives were sent to the
always be distilled to ‘cause and effect’ mechanisms [20]. participants. Once interest was confirmed, they were
Inductive reasoning therefore traverses the rigid struc- provided with a participant information sheet detailing
tural boundaries which govern deductive approaches the purpose of the study and information regarding data
and does not seek to mechanistically verify or oppose confidentiality alongside an informed consent form to
existing theory. Rather, an inductive approach is limit- obtain consent prior to interview conduction. Partici-
less. It utilises a ‘bottom up approach’ beginning with pants were informed that they could withdraw from the
primary data collection followed by the identification of study at any time. This was repeated until no further
patterns and themes in an effort to construct theory recruitment occurred [26] and data saturation was
[23]. Consistent with an inductive approach, this study reached. Data saturation was deemed the point at which
uses qualitative methods focussed on meaning-making, similar responses were being surfaced in the interviews
allowing for a detailed exploration of participants’ lived with repeating rather than novel ideas, referred to by
experiences [24]. Sandelowski [27] as ‘informational redundancy’. In quali-
Methodology is reported in accordance with the Con- tative research, significant ambiguity exists around what
solidated Criteria for Reporting Qualitative Research is deemed an appropriate sample size [20] with limited
Checklist [25]. guidance on this. Guest et al. 2006 suggest that 12 inter-
views are sufficient [28], while Creswell [29] recom-
Sampling mends between 5 and 30 interviews for qualitative
Snowball sampling enabled the recruitment of a team- research. An accepted sample size of between 5 and 25
focused study population, thus facilitating comparison participants has been cited for studies utilising semi-
between the perceptions of different MDT members. structured or in-depth interviews [30]. Therefore, given
This was vital given that psychological safety is a team the fact that data saturation was achieved at 20 inter-
construct. Utilising snowball sampling methodology, a views, this was deemed an appropriate sample size for
sample of 20 individuals from four different primary care the study.
teams (n = 5, n = 6, n = 6, n = 3) were obtained. The sam-
pling approach was employed in two stages. First-line Data collection
participants were recruited through LinkedIn and the Data was collected using semi-structured interviews
Royal Colleges, subject to specified inclusion and exclu- (SSIs), as they are adaptable in nature and allow stake-
sion criteria (Table 1). These participants then recruited holders to share answers openly and independently [31].
colleagues from their multidisciplinary team. For ex- Interviews with all 20 participants were conducted via
ample, to recruit the participants in team 1, the head video-conferencing (due to Covid-19 restrictions). Video
partner GP was contacted through LinkedIn. They then conferencing platforms utilised included Zoom and
initiated contact with the head nurse from the team Skype. Conducting the interviews in this manner offered
which resulted in a sample of five participants in team 1. numerous advantages including; convenience for both
Their employment information was verified at the time the interviewer and the interviewee as well as deducting
of the interview by asking their role in the practice. The travel time, thus increasing efficiency of data collection.
response rate through LinkedIn was approximately 70% Furthermore, this facilitates visual interaction with the
and recruitment was completed in one month. The in- added advantage that it allows the interviewer and inter-
clusion/exclusion criteria were checked prior to the viewee to remain in their own comfortable locations [32].
interview by asking preliminary questions to obtain their However, video-conferencing limited our non-verbal com-
professional role. The roles included were general practi- munication which could have helped contextualise the
tioners, practice managers, partners, healthcare assis- responses. Overall, utilising video-conferencing proved ad-
tants and nurses. The demographic information has vantageous in our data collection process. Interviews were
audio-recorded, anonymised and stored on a secure drive
Table 1 Inclusion and exclusion criteria for participant recruitment before being destroyed post-transcription.
Inclusion Criteria Exclusion Criteria
The interview schedule was designed to be open-
ended to encourage participants to speak freely to allow
Healthcare professionals Healthcare professionals working
working in primary care teams in secondary care teams detailed accounts to be elicited [33]. This was recom-
London primary care teams Non-London primary care teams
mended by the five-step framework by Kallio et al [34]
to create a qualitative interview guide. Kallio et al. rec-
English speaking Non-English speaking
ommended first to evaluate if a semi-structured
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 5 of 12

interview is necessary. The conclusion of conducting in- phase 2, ‘in-vivo’ codes were derived from the data.
terviews was reached as this study needed the percep- Codes were reviewed and compared at the team level in
tions and opinions of our participants in order to phase 3 and were subsequently categorised into themes,
contextualise their answers. Next, a literature review was beginning the process of theory inception. In the fourth
conducted to establish existing knowledge and identify phase, candidate themes and subthemes were reviewed
the gap the interview needs to fill. This helped us with against the coded data to ensure intra-theme coherence
the third step of devising the questions, which included and against the entire data to ensure representability.
the main themes and follow up questions. Further refinement of themes was undertaken in phase 5
As per Kallio et al’s fourth step [34], two pilot inter- before being used to construct a coherent analytic narra-
views with GPs were conducted to verify the initial inter- tive in phase six.
view guide developed. The pilot interviews demonstrated
significant overlap in the interview guide questions Reflexive statement
within the subsection “Roles and Responsibilities”, hence Reflexivity serves as a conscious acknowledgement of
this subsection was summarised into three questions. the researcher’s assumptions and experiences which in-
Secondly, the question ‘How do you view your relation- fluence the research process [40]. This study was con-
ship with other team members? was removed since it re- ducted by a team of seven medical students alongside
quired extensive clarification in both pilots. Finally, one our supervisor, each with varying experiences which
question was added to the interview protocol, ‘Which have shaped our perceptions of primary care. We are
member of the team is most influential in ensuring a aware of our biases towards hierarchy in healthcare
psychologically safe environment?’, due to both inter- teams. However, to reduce the influence of preconceived
viewees referring frequently to the influential role of biases we used open questions to allow free expression
team leaders in facilitating PS within their teams. Yin and had three researchers conduct the interviews to en-
[35] advocates the conduction of pilot studies as an ef- sure triangulation.
fective method for developing ‘relevant lines of informed
questioning’, enabling the refinement of data collection Results
methods. The conduction of pilot interviews further in- This study explored the facilitators and barriers of psy-
formed the modification of the interview guide to ensure chological safety in the four primary care teams. The
data gauged from the questions was sufficient for an- data analysis yielded three meta-themes: Barriers to psy-
swering our research question. chological safety, facilitators of psychological safety, and
The semi-structured interview format allowed for shared beliefs.
probing questions to be used to encourage participants Facilitators and barriers of psychological safety are the
to develop and elaborate on their responses, facilitating main focus of this study, however, the additional meta-
a more detailed inquiry [36]. All SSIs ranged from 20 to theme of shared beliefs was found to be significantly dis-
45 min in duration due to differences in individual avail- tinct from barriers and facilitators. Notably, the meta-
ability and commitment of the respondents. This is in theme shared beliefs refers to the characteristics of the
line with accepted practice in the literature [37]. Three team, including team dynamics and relationships, and
researchers (KR, NA and NH) conducted the interviews hence provides a common basis for the interpretation of
which introduced different perspectives who were able how the facilitators and barriers of psychological safety
to individually interpret the participants’ non-verbal cues influence the respective primary care team. Figure 1
and the emotional aspects which often do not surface in summarises the shared beliefs across the four primary
the transcripts and are only picked up in the interview. care teams, as well as their relation to barriers and facili-
The triangulation of researchers [38] in this manner tators of psychological safety.
minimised individual biases and contributed to the valid-
ity of our research. An interview schedule (Supplemen- Barriers
tary file A) was devised with open-ended questions to The four barriers (hierarchy, lack of knowledge, authori-
encourage participants to speak freely, facilitating a de- tarian leadership, personality) identified in this study
tailed inquiry [33]. were categorised as either organisational, team-based or
individual-level barriers. An overview of the barriers and
Data analysis supporting quotes are shown in Table 2.
Braun and Clarke’s six-phase methodology [39] of the- Hierarchy was identified as an organisational level bar-
matic analysis was utilised for the interview data. Phase rier to psychological safety within team 1. This fostered
1 involved three researchers (RR, NH and AH) transcrib- feelings of inferiority and a perception that other mem-
ing the interviews ad verbatim and developing transcript bers valued their opinions less, increasing hesitancy to
summaries. In line with an inductive approach, within voice opinions. Team-based barriers included a lack of
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 6 of 12

Fig. 1 Illustration of primary care teams with their respective shared beliefs, alongside the barriers and facilitators to psychological safety. Lines
connecting barriers and facilitators to shared beliefs indicate contextual relation

knowledge (team 2, 3 and 4) and authoritarian leader- An overview of the facilitators and supporting quotes
ship (team 3). The perceived lack of knowledge was at- are shown in Table 3.
tributed to a lack of awareness around the respective Leaders (teams 1,2 and 4) were cited as a prominent
discussion topic. This subsequently increased anxiety re- facilitator of psychological safety. Within team 1 and 2,
lated to saying something incorrect or appearing as the leaders exhibiting a friendly attitude, acting in a support-
lone member lacking in knowledge. Furthermore, au- ive manner and inviting participation of members made
thoritarian leadership hindered psychological safety with them influential in facilitating psychological safety. An
individuals feeling that decisions were enforced rather interesting facilitator of psychological safety which sur-
than discussed. This fostered a lack of ownership and faced was that of groups of similar individuals in the
members feeling powerless. Frustrations were two-fold: same profession; silos (teams 1 and 3). Here, psycho-
some participants were discouraged at the domineering logical safety was facilitated via two mechanisms: identi-
approach to decision making, while others expressed fying within the silo which strengthened voice and
concerns over the decisions made. empowerment via a silo leader, an individual with re-
On an individual level, personality was cited as a bar- duced power distance who acted as a spokesperson for
rier to psychological safety. Dominating personalities, the group. For example, several members felt more com-
particularly of those in leadership roles, acted as a bar- fortable approaching their nursing team leader or a GP
rier to psychological safety in Teams 3 and 4, by causing colleague rather than practice leadership directly.
unequal dynamics and participation within conversa- The presence of a boundary spanner, an individual re-
tions. Members also expressed that their opinions had to sponsible for linking sub-groups within the wider MDT,
be repeated multiple times to be heard. Furthermore, was cited by participants in teams 2 and 3 as an influen-
one team member discussed intrinsic barriers such as tial facilitator of psychological safety. Fostering strong
shy personality or a fear of public speaking. interpersonal relationships was an important facilitator
of psychological safety in team 3 and 4. One member
Facilitators contrasted their ability to speak up as a longstanding
The eight key facilitators (leaders and leader inclusive- team member compared to being a newcomer, highlight-
ness, open culture, support in silos, boundary spanner, ing that knowing the team enabled them to speak up.
interpersonal relationships, small groups, vocal personal- The presence of a smaller group made participants of
ity, chairing meetings) identified in this study were cate- Team 4 more comfortable and confident in voicing their
gorised as either team-based or individual-level barriers. opinions.
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 7 of 12

Table 2 Barriers to psychological safety identified in this study

Barrier Quote Level
Hierarchy MDT members such as doctors valued more “Sometimes we can feel the kind of separation like you Organisational
feel like your input is slightly valued less than a doctor’s
would be”
“We have had a few incidences where doctors can talk
down to us as if it’s as though we aren’t as knowledged
as them(…)so it can be a bit soul-destroying sometimes”
Lack of Knowledge Lack of awareness of the cases being “because of working (part-time) (...) I probably don’t know Team based
discussed enough about that particular subject so I won’t speak but
it frustrates me sometimes because I’d like to but I probably
wouldn’t in case I’m saying the wrong thing”
Increased anxiety related to saying something “I realised it was very clear for the rest of the team but me
incorrect or appearing as the lone member as for what action has to be taken clinically. So I kind of
lacking in knowledge wrapped up the discussion because I realised there were a
few things I didn’t think of that were obvious for the rest”
Authoritarian Discussion’s being ‘imposed’ rather than being When the leadership “is not really nice or [is] authoritative Team based
Leadership discussed or rude, then you know, there’s not much [they] can do
Member’s feeling powerless in clinical decision because eventually it’s their practice”
making
Leaders devaluing ideas by team members “You need an essential body of leadership to listen, identify
and act and we don’t have that. There’s loads of people with
good ideas on the ground for the practice but it doesn’t relate
to sensible decisions higher up because it’s kind of a vacuum
of leadership in the centre of the organization.”
Personality Dominant personalities overpowering “There’s quite a mix of personalities and dynamics within the Individual level
conversations group(...)sometimes just trying to get your point across, so you
Other members unable to contribute might have to bring it up several times and you might have
to repeat yourself a few times”
“Sometimes one of the partners might have been a bit more
dominant in their opinion and not everybody liked it “
Intrinsic barriers: shy personality, lack of “I think I’ve got that- the problem with me is feeling embarrassed,
confidence, fear of public speaking & that’s my problem. I don’t think it’s anything to do with the team
personal worries about self-image … they’ve never made me feel stupid”

Individual level facilitators were having a vocal person- dynamics significantly. Whilst the literature reporting on
ality and chairing meetings. Vocal personality was a healthcare teams highlights how the behaviour and per-
prominent facilitator in teams 1 and 3, with members in sonality of a leader specifically can be a barrier to psycho-
team 1 acknowledging their inherent confidence allowed logical safety [4, 41–43], the impacts of dominating
them to voice opinions confidently. An interesting facili- personalities amongst other team members is less ex-
tator reported in team 3 was chairing meetings. Some plored. A shy personality was reported as a barrier, and
participants referred to the dual perspective of the chair- whilst this may be viewed as an innate characteristic, the
ing role, describing that it facilitated them to speak up influence of the team in negating this should be consid-
but they, in turn, acted as a facilitator for others. ered. In contrast, a vocal personality emerged as a facilita-
tor of psychological safety in this study. A relationship
Discussion between personal control and voicing behaviours has been
To the authors’ knowledge, this is the first qualitative documented in healthcare literature, whereby individuals
team-based study investigating barriers and facilitators with greater autonomy feel empowered to speak up [44],
of psychological safety in primary care teams. Obtaining however there is less exploration of the impacts of person-
the viewpoints of different healthcare professionals ality on speaking up behaviours in the context of psycho-
across four primary care teams enabled intra- and inter- logical safety. These findings indicate that psychological
group analysis, on the background of shared beliefs, safety relies on exploring the personality of both oneself
which provided a contextual representation of the team and others in a team in order to establish how individuals
dynamic. The themes that surfaced from this study can can be best supported in the work environment.
be considered at three levels; organisation, team and in- Furthermore, our results identified barriers and facili-
dividual levels. tators at the team level. Our findings revealed that lead-
Barriers and facilitators of psychological safety emerged ership roles are influential as facilitators or barriers to
at an individual level, with personality influencing team psychological safety. Teams 1,2 and 4 highlighted leaders
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 8 of 12

Table 3 Facilitators of psychological safety identified in this study

Facilitator Quote Level
Leader and leader Introducing individuals to the team “The manager makes it a point that they will Team-based
inclusiveness introduce everybody to the new person... so that
you’re not sitting there feeling like nobody knows
who you are and you’re not really allowed to
say anything”
Leader actions and qualities, such as active “The senior clinician asks every single person if
encouragement of participation in MDT there are any issues, if there is something else to
discussion, supportive nature and effective discuss, if they are having any problems”
listening skills
Open culture Non-judgemental atmosphere “Everybody can speak up (...)especially when the Team-based
nurses and healthcare assistants, they’re all chipping
in as well, you do feel very much like I can say
whatever want and (...)it’s quite a safe environment
as well because nobody judges you”
Receptiveness to contributions from all members “Sometimes you might not get an idea, and a
simple layman person may give you an idea that
works. And people accept it, they appreciate it and
that’s why it is easy for us to communicate”
Support in silos Identifying with a group of similar individuals “In the nursing team, we’ve all learnt how to stand Team-based
(a silo) strengthened their voice and created our ground a bit more that also quite important
unity within the subgroup. otherwise it’s a challenge because if a doctor asks
you to do something the kind of traditional idea is
that they are in authority so it can be difficult to
push back”
A silo leader reduced the power distance by “If something happened it’s easier for me personally
acting as a spokesperson for the group. to discuss and explain with my head of nurse than
going to the manager or the partners which might
be easy for my head of nursing team to explain it
further and ask for a solution”
Vocal personality Having an inherent trait that enables an individual Individual-level
to voice opinions confidently.
Boundary spanner The presence of a boundary spanner, an individual This individual was described as essential in ensuring Team-based
responsible for linking sub-groups within the wider “a link between admin and clinical teams”.
MDT, often identified as the practice manager.
Chairing meetings Chairing meetings facilitated individuals to speak “I’m the chair of the meeting so I feel comfortable to Individual- level
up, and in turn, they acted as a facilitator to express myself.”
others speaking up “I’ve also chaired lots of meetings as well so I am aware
of the need to get everyone, to encourage everyone’s
contribution”
Interpersonal Longstanding members with stronger interpersonal “I’ve worked at the practice for five years so I know Team-based
relationships relationships felt more comfortable speaking up everybody very well and we’re all very comfortable in
compared to new individuals to the team. speaking our mind. I think when I first started at the
practice, I was probably a little bit more hesitant to
say my opinions.”
Small teams Small teams help individuals to be more comfortable “I might say it later in a smaller group of um, of GPs Team-based
and confident, whilst preventing individuals feeling and/or nurses but probably not in- in the bigger group.”
outnumbered

who displayed support and inclusiveness as facilitators of centralising control; this phenomenon may not have
psychological safety. Where leadership was not cited as a emerged in teams with multiple GP partners in the lead-
facilitator, it surfaced as a barrier in the form of authori- ership structure. Although this authoritarian leadership
tarian leadership. Literature corroborates this, highlight- style presents benefits in certain situations, such as
ing a correlation between effective or inclusive emergencies occurring commonly in secondary care
leadership and psychological safety in healthcare teams which require fast decision making by a single leader
[2, 7, 12, 18, 21, 45–47]. In contrast, leader unreceptive- [48],, this is arguably less applicable and useful in pri-
ness has been reported as a barrier to raising patient mary care. Crucially, high-performing healthcare organi-
concerns [18, 19]. A key differentiator between the sations are associated with broad leadership
teams is their leadership structure in the GP practice. distributions [49]; our findings suggest that this should
Members of a mono-leadership referred to their leader be reflected in primary care.
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 9 of 12

Through this study, various leadership traits emerged findings show that providing individuals with the op-
as facilitators to psychological safety, offering practical portunity to chair meetings can facilitate voicing be-
actions that can be adopted going forwards. This in- haviour amongst members who are typically reluctant
cludes showing support, actively listening to team mem- to speak up.
bers and inclusive behaviours, such as encouraging Of particular note is the obstructive effects of hier-
contributions or introducing new members of the team archy on psychological safety. The hindering nature of
to their colleagues. Developing these positive leadership hierarchy is supported by literature, and both our study
traits is an important step for the NHS, with action alongside other research highlight that open cultures can
already demonstrated by the General Practice Forward help to negate the impact of hierarchy [61]. However,
View (GPFV), which states that a larger proportion of adopting a team view on hierarchy and open cultures is
the primary care budget is being allocated towards the perhaps too restrictive; rather, a broader view which en-
leadership development of more senior GPs [50]. These compasses the entire healthcare organisation is war-
findings are further supported by the literature, which ranted. Hierarchy is a deep-rooted cultural aspect of
has highlighted the correlation between effective leader- healthcare, and while some literature suggests that it can
ship behaviours and psychological safety in healthcare improve role clarity and coordination within teams [62],
teams [46, 47, 51] Additional traits that should be it is becoming apparent that the resulting detriment to
adopted by healthcare leaders highlighted by literature teams should be further acknowledged in healthcare
include transformational leadership behaviours [52], en- [63]. Our study has shed light on the numerous methods
couraging innovative change [2] and displaying role- by which teams can help to foster psychological safety.
modelling behaviours [15, 43, 53, 54]. However, if the underlying problems surrounding hier-
Associating within a silo enabled members in teams 2 archies are not addressed at the organisational level, it
and 3 to speak up. It appears counterintuitive that will still be difficult to foster psychological safety. We
profession-based silos, often considered destructive to propose larger organisations such as professional bodies
team cohesiveness [55], could facilitate psychological work towards informing key stakeholders - both clini-
safety. Perhaps individuals find ‘strength in numbers [56] cians and management teams, of the benefits of psycho-
and subsequently leverage their silos to be heard. This logical safety as well as the role of hierarchy as a barrier
appeared to be particularly noted in teams who reported to implementing this.
poor leadership and a prominent hierarchy, both of An element of hierarchy may also be responsible for
which emerged as barriers to psychological safety. Al- perceived lack of knowledge acting as a barrier, where
though we have identified support in silos as a potential those ‘lower’ in hierarchy status incorrectly assume
facilitator of psychological safety, caution is needed re- others in the team possess more important information
garding its practical use. It is possible that this emerges and consider their own knowledge to be irrelevant to the
within teams lacking psychological safety, resulting in a discussion [64]. These cognitive biases can have detri-
reliance rather than support within the silos. This is a mental effects to patient safety, where individuals do not
novel finding, and further research is required to investi- raise crucial information resulting in patient harm [65].
gate the underlying role of silos in ensuring psycho- Many junior HCPs also struggle to speak up against se-
logical safety. nior, more experienced colleagues when errors are oc-
As shown by Jain et al [57], our results also demon- curring, due to an assumption of superior knowledge
strated the importance of a boundary spanner as a facili- possessed by their supervisors [66]. These findings where
tator of psychological safety. However, our study builds a perceived lack of knowledge acts as a barrier to psy-
on existing literature by suggesting that the practice chological safety are widely supported by existing litera-
manager, a non-clinical member of a primary care team, ture on healthcare teams [43, 51, 67]. This indicates that
is most appropriate for this role. This likely stems from building the confidence of each individual team member
their knowledge of both clinical and non-clinical activ- is a fundamental step to increasing psychological safety,
ities occurring within a GP practice [58]. This was a fa- with the leader’s role being to validate input and encour-
cilitator common to two highly contrasting teams (teams age contribution from every individual, regardless of
2 and 3), built on different underlying shared beliefs. As position.
primary care teams become increasingly diverse [59],
our findings therefore call for the designation of a Limitations
boundary spanner, given their inextricable value for uni- The findings of this study should be considered in the
fying any team regardless of underlying dynamics. Fur- context of several limitations. Firstly, we were unable to
thermore, given this increasing diversity in healthcare recruit every team member from the four primary care
teams, the traditional hierarchical view whereby doctors teams, and therefore may have missed key viewpoints.
are seen as ‘automatic leaders’ [60] is outdated. Our Secondly, despite the effectiveness of snowball sampling
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 10 of 12

for recruitment, this method can incur selection biases engage in to directly facilitate or impede psychological
as participants are recruited upon referral [68]. Finally, safety. By strengthening interpersonal relationships, en-
this study was conducted during the COVID-19 pan- couraging a rotating chairperson for meetings and find-
demic where primary care was overstretched resulting in ing support in silos to reduce power distances, a team
heightened workplace stress and altered team dynamics. can create a positive team culture that ultimately sup-
These unique circumstances may have altered partici- ports psychological safety. It is anticipated that these
pants’ opinions of psychological safety within their team, findings will encourage primary care teams to reflect on
which may have impacted our data. their team dynamics and adopt the aforementioned
strategies to ensure every member’s voice is heard.
Implications for practice
This study offers a unique insight to the specific barriers Supplementary Information
and facilitators of psychological safety in primary care, The online version contains supplementary material available at https://doi.
org/10.1186/s12913-021-06232-7.
identifying tangible changes that can be adopted at the
individual, team and organisation level. The importance
Additional file 1: Supplementary file A- Interview Schedule.
of psychological safety in healthcare is well established,
underpinning the patient care that is provided and hold-
Acknowledgements
ing potential to benefit both healthcare workers and pa- Not applicable.
tients alike [7, 69].
Authors’ contributions
RR, AH, NH and KR are co-first authors and have contributed substantially to
Implications for future research the conduct of this study and the writing of the manuscript. KR, NA and NH
During this study, common themes arose regarding were responsible for data collection. RR, NH and AH were responsible for
perceptions of psychological safety in primary care. Pro- transcribing, coding, data analysis and interpretation. NA, AM and SGT
substantially contributed to the study design, recruitment, interview
fession based differences are reported in literature, how- schedule and preliminary drafts of the work. EM substantially contributed
ever, are often generalised across healthcare [70–72]. A to the conception and design of the study, forming the basis of the
direct focus on profession analysis would provide an im- thematic analysis used, and made substantial revisions to the manuscript,
alongside overseeing the overall study conduct. The authors read and
portant insight to the field of psychological safety. By approved the final manuscript.
identifying profession specific attitudes, barriers and fa-
cilitators, personalised support can be offered to increase Authors information
the psychological safety within general practice. RR is a female 6th year medical student but was a 5th year medical student
at the time of the study.
Importantly, many of the underlying barriers to psy- AH, NH, KR and AM are female 5th year medical students, but were 4th year
chological safety appear to be ingrained into the culture medical students at the time of the study.
of the healthcare system. This would require multifa- NA and SGT are male 5th year medical students but were 4th year medical
students at the time of the study.
ceted changes to deep-rooted beliefs and systems, with EM (PhD) is a male professor at Leeds Business school. At the time of the
scope for future research to identify the most effective study, EM was an associate Dean at Imperial College London business
methods to achieve this. Alongside these efforts, the school.

focus should be directed on the new generation of Funding

healthcare professionals and students. Psychological Funding was not required for this study.
safety remains a relatively unknown concept to both
Availability of data and materials
healthcare students and educators alike [73]. Further re-
The datasets generated and analysed during the current study are not
search should explore their experience and perceptions publicly available but are available from the corresponding author on
of psychological safety, particularly whilst exposed on reasonable request.
clinical placements, and identify methods to equip stu-
Declaration
dents with the ability to ensure psychological safety is
prominent within their future multidisciplinary teams. Ethics approval and consent to participate
This study was granted Ethical Approval by Imperial College Research Ethics
Committee (ICREC). Informed, written consent was obtained from all participants.
Conclusion
This qualitative study aimed to identify facilitators and Consent for publication
barriers of psychological safety in primary care, consid- Not applicable.
ered at the individual, team and organisation levels.
Competing interests
Leaders are influential within a team since their behav- The authors declare that they have no competing interests.
iours can directly facilitate or act as a barrier to psycho-
logical safety. However, our study highlights that the Author details
1
College of Medical and Dental Sciences, University of Birmingham,
responsibility and influence does not solely lie with the Birmingham, UK. 2Imperial College London, School of Medicine, London, UK.
leader. Rather, there are several behaviours the team can 3
Leeds University Business School, University of Leeds, Leeds, UK.
Remtulla et al. BMC Health Services Research (2021) 21:269 Page 11 of 12

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